Dual paradoxical reactions in tuberculous lymphadenitis during and after pregnancy: A case report

We report the case of a 23-year-old woman with tuberculous lymphadenitis diagnosed prior to pregnancy who developed paradoxical lymph node enlargement during pregnancy and again in the post-partum period. Despite completing a full 9-month course of standard anti-tuberculosis therapy, she experienced recurrent cervical lymphadenopathy and a transient pulmonary opacity following delivery. Extensive investigations, including repeat biopsies and cultures, excluded relapse or drug resistance, supporting the diagnosis of a paradoxical reaction. She was managed conservatively with drainage procedures, nonsteroidal anti-inflammatory drugs, and close monitoring, without the need for additional anti-tuberculosis medications or corticosteroids. Her lymphadenopathy resolved and she remained systemically well. This case is unique, as an extensive literature search in MEDLINE via PubMed and Embase from inception to September 2025 revealed no previously reported cases of paradoxical tuberculosis reactions occurring during pregnancy. This case underscores the importance of distinguishing paradoxical reactions from treatment failure, avoiding unnecessary therapy changes, and recognizing that conservative management is often sufficient in pregnancy and post-partum settings.